Telehealth alternatives to in-person consultation found lacking in effectiveness: Alt-Con Study (UK)

It needs work and can’t be top down. That’s the conclusion of the Alt-Con Project and its researchers from several UK universities: Warwick, Bristol, Oxford (Nuffield) and Edinburgh. After examining the use of technological alternatives to GP consultations in eight general practices, they found that there were significant barriers to implementation, including insufficient training of non-clinical staff on these approaches’ benefits. The study includes recommendations to guide a more effective implementation.

Practices have been slow to adopt tech alternatives to F2F consults using telephone, email, e-consultation systems, and online video, despite NHS encouragement and programs such as the GP Access Fund. The paradox is that time devoted to non-F2F consults cuts into GPs time seeing live patients in the office.

  • They were adopted without a clear rationale or clearly thinking through cost-benefit for patients and practice staff.
  • Professor Sue Ziebland from Nuffield found that “…practices introduced alternative consultation methods for very different reasons and to solve problems that the practice had identified. These included a failure to be modern, to work more efficiently, to better serve commuters or dispersed populations, and to ensure appointments were available to those who needed them most.”
  • Other reasons: “the acknowledgment that the previous system was broken and unethical in providing a first-come, first-served system that left patients without appointments that they needed, and “the recognition that reception staff and phone lines were overwhelmed.”
  • Noted by other researchers were that ‘one-size-fits-all’, policy and financial incentive driven approaches were “not the best way forward”.

The study looked at GP practices of different sizes (1,938 to 18,353) covering over 85,000 patients, located in different geographic areas of England (6) and Scotland (2) including urban and rural areas, and with a mixture of patients’ socioeconomic status. 45 staff members and 39 patients were interviewed over eight months.

The University of Bristol Centre for Academic Primary Care has published a web page based on the Alt-Con research, offering guidance for GP practices. 

NHS England’s rejoinder: ‘This is a tiny study based on data that is almost two years old. Online consultations offer a convenient alternative to face-to-face appointments and patients are already seeing the benefits.’ Nuffield Department of Primary Care release, British Journal of General Practice, Daily Mail  Hat tip to former TTA Ireland editor Toni Bunting

Babylon Health’s ‘GP at hand’ not at hand for NHS England–yet. When will technology be? Is Carillion’s collapse a spanner in the works?

NHS England won’t be rolling out the Babylon Health ‘GP at hand’ service anytime soon, despite some success in their London test with five GP practices [TTA 12 Jan]. Digital Health cites an October study by Hammersmith and Fulham CCG (Fulham being one of the test practices) that to this Editor expresses both excitement at an innovative approach but with the same easy-to-see drawback:

The GP at Hand service model represents an innovative approach to general practice that poses a number of challenges to existing NHS policy and legislation. The approach to patient registration – where a potentially large volume of patients are encouraged to register at a physical site that could be a significant distance from both their home and work address, arguably represents a distortion of the original intentions of the Choice of GP policy. (Page 12)

There are also concerns about complex needs plus other special needs patients (inequality of service), controlled drug policy, and the capacity of Babylon Health to expand the service. Since the October report, a Babylon spokesperson told Digital Health that “Commissioners have comprehensively signed off our roll-out plan and we look forward to working with them to expand GP at Hand across the country.” 

Re capitation, why ‘GP at hand’ use is tied into a mandatory change of GP practices has left this Editor puzzled. In the US, telemedicine visits, especially the ‘I’ve got the flu and can’t move’ type or to specialists (dermatology) are often (not always) separate from whomever your primary care physician is. Yes, centralizing the records winds up being mostly in the hands of US patients unless the PCP is copied or it is part of a payer/corporate health program, but this may be the only way that virtual visits can be rolled out in any volume. In the UK, is there a workaround where the patient’s electronic record can be accessed by a separate telemedicine doctor?

Another tech head-shaker: 45 percent of GPs want technology-enabled remote working. 48 percent expressed that flexible working and working from home would enable doctors to provide more personalized care. Allowing remote working to support out-of-hours care could not only free up time for thousands of patient appointments but also level out doctor capacity disparities between regions. The survey here of 100 GPs was conducted by a cloud-communications provider, Sesui. Digital Health. This is a special need that isn’t present in the US except in closed systems like the VA, which is finally addressing the problem. The wide use of clinical connectivity apps enables US doctors to split time from hospital to multiple practices–so much so on multiple devices, that app security is a concern. 

Another head-shaker. 48 percent of missed NHS hospital appointments are due to letter-related problems, such as the letter arriving too late (17 percent), not being received (17 percent) or being lost (8 percent). 68 percent prefer to manage their appointments online or via smartphone. This preference has real financial impact as the NHS estimates that 8 million appointments were missed in 2016-2017, at a cost of £1bn. Now this survey of 2,000 adults was sponsored by Healthcare Communications, a provider to 100 NHS trusts with patient communications technology, so there’s a dog in the hunt. However, they developed for Barnsley Hospital NHS Foundation Trust a digital letter technology that is claimed to reduce outpatient postal letters by 40 percent. Considering my dentist sends me three emails plus separate text messages before my twice-yearly exam…. Release (PDF).

Roy Lilley’s daily newsletter today also engages the Tech Question and the “IT desert” present in much of the daily life of the NHS. Trusts are addressing it, junior doctors are WhatsApping, and generally, clinicians are hot-wiring the system in order to get anything done. It is much like the US about five to seven years ago where US HHS had huge HIPAA concerns (more…)

Is ‘relationship medicine’ enough to kickstart telemedicine?

Investor Todd Hixon (New Atlantic Ventures) opines in Forbes about the ‘new paradigm’ of relationship medicine, with the primary care doctor at its center and responsible for the patient’s long-term health quality. He admits that the concept, in some respects, resembles the 1950s days of the local GP who knew everything about everybody, but where he posits the telemedicine ‘inflection point’ is the ability to create a link between the doctor and patient that is efficient as well as effective via virtual video consults, email, text and phone. He then jumps to the notion (more…)

GP-critical survey sort-of revealed – or is it? (UK)

When publications like Pulse manage to insert the historic, and wholly-unrepresentative-of-telehealth, cost/QALY from the Whole System Demonstrator into an article twice in a week (here & here), and the Royal College of General Practitioners produces a vision of a GPs life in 2022 that essentially ignores technological progress, it is hard for a publication such as Telehealth & Telecare Aware to appear fair and unbiased, so it is great to have an opportunity to redress the balance.

The occasion is  (more…)

At last a supportive article on telehealth! (UK)

Richard Vize has written a highly-recommended article in the Guardian today entitled “GPs continue to do battle with government over telehealth”. This gives some valuable context to why publications such as Pulse continue to dredge up the historic Whole System Demonstrator (WSD) cost/QALY statistics as it did on Wednesday and  Thursday last week.

TTA readers will of course be aware of the reasons why those figures are so unrepresentative of the technology from our recent post on why it’s time to bid farewell to the WSD.

Particularly pleasing is to see recognition of the role of telehealth as a means of promoting wider improvement in the way care is delivered:

“Eventually, other costs will start to fall as telehealth becomes a catalyst for wider system change. At present it is a bolt-on to a care system poorly integrated and not adapted for telehealth. It will require clinicians to work together in new ways, particularly in more effective joint working between community and hospital staff.”

Future GP consultation – boring but very important (England)

NHS England has just launched a consultation on the future of GP practices, with a slide set of the case for change and the NHS’s underlying objectives for general practice together with an evidence pack which provides some information about current general practice and health needs.

This is important to everyone who senses that modern technology can help make a real difference to the way care is delivered because there is a serious lack of ambition (more…)

“A rose by any other name would smell as sweet” (UK telehealth)

60 Second GP today points to an article on what looks to be essentially a Simple Telehealth-type application, in this case a GP-led internet-based programme to encourage weight loss among obese patients in West Oxfordshire.  What makes it newsworthy is that it never mentions telehealth, yet extolls the benefits in a manner that any telehealth project or programme manager, eager for clinical acceptance will instantly recognise, such as:

  • “An internet-based programme can involve GPs in the weight loss of a large number of patients in a cost-effective manner.”
  • “The main benefit of the programme is that it dramatically reduces the cost of face-to-face time with patients, freeing up healthcare professionals for other activities.”

Does this mean that the good GPs of West Oxfordshire have taken onboard a previous Telecareaware post “When mHealth and telehealth become ‘just healthcare’” ?

I somehow doubt it – however the article is nevertheless recommended reading for anyone wanting to sell successfully a telehealth programme to clinicians without ever mentioning the ‘t’ word.

Also worth pointing out is that a feature of the programme was to introduce some gamification – in this case via a league table of weight losers, where anonymised patients reported changes in weight, so other could compare achievements.  Perhaps that’s why the authors, Professor David Brodie, Emma Doyle, Dr Jey Radhakrishnan and Dr David Shaw, report that “One of the most striking outcomes was the high number of men who lost weight (almost 90%), because men are often more reluctant to become involved in weight loss programmes”? (For another great example of gamification applied to weight loss, without the technology, see Fitfans in Hull.)

Sadly there is no information in the article on the size of the programme…and the implication seems to be that having been shown to be successful it was discontinued after 12 months.